Antibiotics, Vaginal
PDL Reference Documents
PDL Status Values
Y = preferred
N = non-preferred. Non-preferred drugs listed as N but without clinical drug use criteria are subject to the
Non-Preferred Drugs in Select PDL Classes prior authorization criteria.
New drugs will be listed as N until reviewed by the P&T Committee and are subject to the
New Drug Policy.
V = voluntary non-preferred. Non-preferred mental health drugs are listed as V and prior authorization is not required.
Null (i.e. blank) = indicates the class or specific drug has not been reviewed for PDL placement.
To request a Prior Authorization, please use this form.
| Generic Name | Brand Name | Form | PDL Status |
Current Drug Use Criteria | New Drug Evaluation |
|---|---|---|---|---|---|
| clindamycin phosphate | CLINDAMYCIN PHOSPHATE | CREAM/APPL | Y | ||
| clindamycin phosphate | CLEOCIN | CREAM/APPL | Y | ||
| clindamycin phosphate | CLEOCIN | SUPP.VAG | Y | ||
| metronidazole | METRONIDAZOLE | GEL W/APPL | Y | ||
| metronidazole | VANDAZOLE | GEL W/APPL | Y | ||
| clindamycin phosphate | CLINDESSE | CRM ER (G) | N | ||
| clindamycin phosphate | XACIATO | GEL W/APPL | N | ||
| metronidazole | NUVESSA | GEL W/APPL | N | ||
| secnidazole | SOLOSEC | GRANDR PKT | N | ||
| tinidazole | TINIDAZOLE | TABLET | N |